Open Access
Short Report
The happy docs study: a Canadian Association of Internes and Residents well-being survey examining resident physician health and satisfaction within and outside of residency training in Canada Jordan S Cohen*
1, Yvette Leung
2, Meriah Fahey
3, Linda Hoyt
4, Roona Sinha
5, Lisa Cailler
6, Kevin Ramchandar
7, John Martin
8and Scott Patten
9Address: 1University of Calgary Faculty of Medicine, Foothills Medical Center, Assistant Clinical Professor in the Department of Psychiatry, Calgary, Alberta, Canada, 2University of Calgary, Fellow in the Department of Gastroenterology, Calgary Alberta, Canada, 3University of Manitoba, Resident in the Department of Obstetrics, Gynecology and Reproductive Sciences, Winnipeg, Manitoba, Canada, 4Dalhousie University, Resident in the Department of Psychiatry, Halifax, Nova Scotia Canada, 5University of Alberta, Resident in the Department of Pediatrics, Edmonton, Alberta, Canada, 6University of British Columbia, Resident in the Department of Radiation Oncology. Vancouver, British Columbia, Canada,
7McMaster University, Resident in the Department of Radiation Oncology. Hamilton, Ontario, Canada, 8Memorial University, Resident in the Department of Pediatrics. St. John's, Newfoundland, Canada and 9University of Calgary Faculty of Medicine, Department of Community Health, Calgary, Alberta, Canada
Email: Jordan S Cohen* - jordan.cohen@calgaryhealthregion.ca; Yvette Leung - ypyleung@telus.net;
Meriah Fahey - meriah_fahey@hotmail.com; Linda Hoyt - Linda.Hoyt@dal.ca; Roona Sinha - sinha@ualberta.ca;
Lisa Cailler - caillier@interchange.ubc.ca; Kevin Ramchandar - kevin_ramchandar@pairo.org; John Martin - johnh_martin@hotmail.com;
Scott Patten - patten@ucalgary.ca
* Corresponding author
Abstract
Background: Few Canadian studies have examined stress in residency and none have included a large sample of resident physicians. Previous studies have also not examined well-being resources nor found significant concerns with perceived stress levels in residency. The goal of "The Happy Docs Study" was to increase knowledge of current stressors affecting the health of residents and to gather information regarding the well-being resources available to them.
Findings: A questionnaire was distributed to all residents attending all medical schools in Canada outside of Quebec through the Canadian Association of Internes and Residents (CAIR) during the 2004–2005 academic years.
In total 1999 resident physicians responded to the survey (35%, N = 5784 residents). One third of residents reported their life as "quite a bit" to "extremely" stressful (33%, N = 656). Time pressure was the most significant factor associated with stress (49%, N = 978). Intimidation and harassment was experienced by more than half of all residents (52%, N = 1050) with training status (30%, N = 599) and gender (18%, N = 364) being the main perceived sources. Eighteen percent of residents (N = 356) reported their mental health as either "fair" or "poor". The top two resources that residents wished to have available were career counseling (39%, N = 777) and financial counseling (37%, N = 741).
Conclusion: Although many Canadian resident physicians have a positive outlook on their well-being, residents experience significant stressors during their training and a significant portion are at risk for emotional and mental health problems. This study can serve as a basis for future research, advocacy and resource application for overall improvements to well-being during residency.
Published: 29 October 2008
BMC Research Notes 2008, 1:105 doi:10.1186/1756-0500-1-105
Received: 4 June 2008 Accepted: 29 October 2008 This article is available from: http://www.biomedcentral.com/1756-0500/1/105
© 2008 Cohen et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Findings
The goal of the survey was to increase knowledge of cur- rent stressors affecting the well being of residents and to gather information regarding the well-being resources available to them.
Methods
The CAIR Happy Docs Study was conducted during the 2004–2005 academic year. The CAIR membership list served as the sampling frame for the study. CAIR via its membership represents all resident physicians employed in Canada, with the exception of resident physicians in the province of Quebec. The entire resident population indexed in the sampling frame was considered eligible for inclusion. This included residents from all training pro- grams for all post-graduate years of residency. This volun- tary study was distributed to residents in the sampling frame and collected by CAIR board members in each region. Academic days, local mailboxes, e-mail communi- cation, and websites were all tools used to help promote and distribute the surveys [see Additional file 1].
The goals of the study were broad-based and descriptive.
The questionnaire was divided into five sections: demo- graphics, stress, intimidation and harassment, well-being and resources. Survey questions included qualitative rat- ing scales, multiple choice responses and yes/no ques- tions. To minimize response acquiescence bias in rating scales responses, the survey included a mixture of posi- tively and negatively stated items [1]. To ensure adequate content validity, the survey stress questions were devel- oped by a study team that consisted of residents and thus contained items that referred to the actual concept of stress that were most germane to residency. The well- being items from the CCHS come from a fully validated instrument developed by Massé and associates [2]. Items derived from Statistics Canada have undergone extensive field-testing and focus group evaluation.
The stress section of the survey contained questions regarding sources of stress as well as methods for dealing with stress. The terms "stress" and "intimidation and har- assment" were not formally defined in the survey to allow measurement of "perceived stress" and "perceived intimi- dation and harassment" which may vary both quantita- tively and qualitatively among individuals. Well-being questions were derived from the Canadian Community Health Survey (CCHS) so that results could be compared with members of the general Canadian population [3].
Mental illness screening questions from the CCHS were also included to identify possible psychiatric symptoms in residents. Questions on resources focused on knowledge of current resources, perceived need for future resources, and barriers and limitations to resident physicians seeking aid.
Statistics
Statistical analysis was conducted with help from the Canadian Post MD Educational Registry (CAPER).
Descriptive statistics were used to give an overview of the data as well as for comparison with the CCHS. In cases where not all residents responded to individual questions, percentages fall short of 100%. Percentages reported for different forms of intimidation and harassment reflect the overall percent of residents completing the entire survey and not those that reported intimidation and harassment, except where directly quoted in text. Confidence intervals, Chi-squares, and Fisher exact tests were used to compare differences between groups. P-values less then 0.05 were interpreted as indicating a statistical difference. Where numbers were large enough for valid statistical inference, groups were stratified.
Results
(A) Demographics
Overall, 1999 resident physicians responded to the sur- vey, which accounted for 35% of the 5784 residents in the sampling frame. Regional response rates are noted in Table 1 and vary from 28% to 51%. The gender distribu- tion was 47% (N = 942) male and 52% (N = 1043) female. Respondents came from all years of post-graduate training with 31% (N = 612) in their first year, 28% (N = 556) in second year and 42% (N = 831) in their third year of post-graduate medical training or higher.
Average hours worked per week were 1% (N = 13) less than or equal to thirty five hours per week, 11% (N = 213) worked on average thirty five to fifty hours per week, 26%
(N = 514) worked fifty one to sixty five hours per week, 39% (N = 787) worked sixty six to eighty hours per week, and 22% (N = 435) worked more than eighty hours per week.
(B) Stress
One third of residents reported that most days of there life were "a bit" to "extremely stressful" (33%, N = 656). In the last 12 months, 41% (N = 820) of residents reported most days to be "quite a bit" to "extremely" stressful. Time pressure was the most reported source of stress by resi- dents (Table 2). Overall, males reported less "extreme"
stress due to time pressure (33%, N = 310/942) as com- pared to their female counterparts (41%, N = 432/1043).
Demographic associations with factors contributing to stress There was a statistically significant relationship between sources of stress and many of the demographic groups of residents (Table 3).
Ways of dealing with Stress
Individuals reported both positive and negative coping mechanisms in dealing with stress during their residency
training (Table 4). 92% of respondents (N = 1839) spoke with others while 17% (N = 342) used alcohol to cope with stress. Approximately 16% (N = 316) of residents surveyed reported considering changing their residency program. When residents were asked if they could relive their lives, would they pursue another career, 23% (N = 466) said yes.
(C) Intimidation and Harassment
As seen in Figure 1, residents reported intimidation and harassment most often from nursing staff (54%, N = 1070) and staff physicians (39%, N = 781). The majority of the intimidation and harassment was experienced in
the form of inappropriate verbal comments (66%, N = 1330). The perceived basis for the intimidation and har- assment was mainly training status (30%, N = 599), or gender (18%, N = 364).
(D) Well-being
The results for life satisfaction and self-rated mental health used in this survey are compared to the CCHS esti- mates (ages 26 to 64 years) for the Canadian population in Figure 2 and 3, respectively.
Perceived life satisfaction/well-being
When asked about satisfaction with life in general, 78%
(N = 1551) of residents reporting being "satisfied" (Figure 2). The majority of residents reported "excellent" to "very good" (N = 993, 50%), or "good" physical health (N = 662, 33%), with 17% perceiving their physical health as
"fair" to "poor" (N = 334). Mental health ratings as com- pared to the Canadian Community Health Survey are also presented in Figure 3.
History of emotional or mental health problems
Almost one-third of residents (30%, N = 607) reported having experienced a mental health problem. Fourteen percent (N = 290) consulted a psychiatrist or psychologist for help in their life. Almost one quarter of residents reported experiencing an emotional or mental health con- cern during training (23%, N = 453).
Table 1: Response rate distribution by region
Region Number and Percent Response Number of Eligible Residents Response Rate
Newfoundland N 196 54
% 100% 28%
Maritimes N 400 118
% 100% 30%
Ontario N 3136 1011
% 100% 32%
Manitoba N 374 127
% 100% 34%
Saskatchewan N 210 47
% 100% 22%
Alberta N 813 414
% 100% 51%
British Columbia N 655 228
% 100% 35%
Total N 5784 1999
% 100% 35%
Table 2: Distribution of factors associated with high stress in residency (scores of 4 or 5 on 5 point scale)
Source of Stress N Percent (%)
Time pressure 1403 70
Own work situation 847 43
Financial situation 758 38
Residency program 631 32
Personal relationship 492 24
Own personal or family responsibilities 439 22 Own emotional mental health problem 280 14
Employment status 267 14
Own physical health problem 268 13
Caring for own children 230 12
Caring for others 203 10
Discrimination 128 7
Personal/family safety 91 4
Psychiatric illness screening
CCHS screening questions were used to identify possible psychiatric symptoms in residents.
Positive predictive values (PPV) of the screening questions for each disorder (generalized anxiety disorder was not completed in CCHS) were used to predict lifetime risk of each psychiatric disorder (Table 5).
Significant associations with Mental Health
Residents reporting "poor" to "fair" mental health indi- cated they deal with stress by drinking alcohol often (6%, N = 21/356), compared to those reporting "good" mental health (2%, N = 11/663), or "excellent" mental health (1%, N = 9/969) [P < 0.001]. Residents reporting "poor"
to "fair" mental health indicated they would change resi- dency programs if they could live their life over again, more often (28%, N = 101/356), compared to residents reporting "good" (19%, N = 129/663), or "excellent"
mental health (9%, N = 85/969) [P < 0.001]. Residents reporting "poor" to "fair" mental health indicated they would choose a new career (outside of medicine) if they could live life over again (45%, N = 159/356), more often compared to residents reporting good (26%, N = 174/
663), and excellent mental health (14%, N = 133/969) [P
< 0.001].
Residents reporting "fair" to "poor" mental health were more likely to report financial stress (51%, N = 181/356), compared to residents reporting "good" (43%, N = 284/
663), or "excellent" mental health (30%, N = 288/969) [P
< 0.001]. Better mental health was associated with being involved in a relationship ("excellent" or "very good"
mental health, 58%, N = 562/969; "good", 58%, N = 387/
663; compared with "fair" to "poor" mental health, 48%, N = 172/356) [P < 0.001].
(E) Resources
Residents most frequently reported wanting career coun- seling (39%, N = 777) and financial counseling (37%, N
= 741) as a priority. Program ombudsman and resident support group were also identified as desired resources (27%, N = 545 and 23%, N = 466 respectively). Resident colleague (65%, N = 1305), program director (53%, N = 1066), psychiatrist/psychologists (49%; N = 982), chief resident (45%; N = 904) and support telephone lines (33–
44%, N = 667–815) were highest ranked as currently
Table 3: *Highlighted differences among demographic subgroups contributing to significant resident differences when reporting sources of stress
Demographic Group Subgroups Possible Stress Factors Contributing to differences in subgroups
Age < 27 years and 27–30 years Increased stress reported for all factors except "caring for own children" (e.g. time pressure 69%, N = 662/960)
Gender Men Increased stress reported for finances (64%, N = 154/241),
employment status (61%, N = 14/23), and discrimination (65%, N = 13/20).
Women Increased stress for mental health (55%, N = 23/42)
Relationship status Single Increased stress with personal relationship (55%, N = 57/103)
Location of MD training MD outside of Canada Overall less stress reported, except for discrimination (65%, N = 13/20)
Residency year of training PGY-3 or above Increased stress due to time pressure (42%, N = 413/974), financial (42%, N = 100/241), employment status (87%, N = 20/23)
PGY-1 More stress for own work situation (48%, N = 102/214)
Range of hours worked/week 51–65 & 66–80 average hours per week worked Increased reporting of time pressure as a stress (69%, N = 665/961)
* Note: not all potential differences within a demographic group MD = Medical degree
PGY = postgraduate year
Table 4: Frequency of different responses of dealing with stress (reported by residents as occurring often or sometimes)
Response to stress N Percent (%)
Talk to others 1839 92
Relax by doing something enjoyable 1808 90 Look on the bright side of things 1793 89
Jog or do other exercise 1512 76
Wish the situation would go away 1383 70
Avoid being with people 1027 52
Blame yourself 1009 50
Eating more or less than usual 953 47
Sleep more than usual 896 45
Pray or seek spiritual help 758 38
Drinking alcohol 342 17
Using drugs or medication 105 5
Smoking more cigarettes than usual 81 4
available resources residents would use in a time of per- sonal crisis. When asked what would they do if they sus- pected that one of their colleagues was experiencing an emotional or mental health problem, most residents reported either suggesting that to their colleague to get help (88%, N = 1754), or offer to escort their colleague to
"get help" (75%, N = 1503).
Conclusion
Limitations of the Study
Although the survey response rate of 35% was comparable to other Canadian studies like the National Physician Sur- vey and other resident surveys [4,5], it does lead one to
question a vulnerability to bias. The results are to some extent more representative of residents who are earlier in their training since junior residents made up half of the sampling frame while 59% of the respondents. Many fac- tors are associated with postgraduate year level that may reflect a response bias leading to an increased reporting of stress (i.e. experience and hours of work). Previous studies have also indicated that the first year of residency is an independent factor contributing to burnout [6]. However, seniority in training has other stresses that may be equally concerning to residents (e.g. final examinations, higher expectations). One must also wonder whether the results are due to a reporting bias among genders, in that females Frequency of groups perceived by residents as being intimidating and harassing to residents
Figure 1
Frequency of groups perceived by residents as being intimidating and harassing to residents.
Pr ogr am dir ector (8% )
Residents in own pr ogr am (9% )
Other Residents (25% )
Residents in other pr ogr ams (29% )
Staff physicians (39% )
Patients (45% )
Nur sing Staff (54% )
Comparison of relative frequencies of self rated life satisfaction results between residents from the study and the Canadian population
Figure 2
Comparison of relative frequencies of self rated life satisfaction results between residents from the study and the Canadian population.
0 10 20 30 40 50 60 70 80 90
Very Satisfied or
Satisfied
Neither satisfied nor
dissatisfied
Dissatisfied or v ery dissatisfied
Happy Doc Life Satisfaction CCHS Life Satisfaction
Happy Doc Mental Health
CCHS Mental Health
%
Comparison of relative frequencies of self rated mental health results between residents from the study and the Canadian pop- ulation
Figure 3
Comparison of relative frequencies of self rated mental health results between residents from the study and the Canadian population.
0 10 20 30 40 50 60
Excellent to v ery
good
Good Fair to poor
Happy Doc Mental Health
CCHS Mental Health
%
tend to be more open about their stress than their male counterparts. This study did not separate residency spe- cialties and thus we were unable to comment on whether well-being results reflected individual medical residency programs. The stigma of mental illness may have pre- vented full disclosure and/or abstinence from the survey altogether. Prior studies in medical students have reported poor response rates due to fear of anonymity and confi- dentiality within the study [7].
Although many Canadian resident physicians have a pos- itive outlook on their well-being, residents experience sig- nificant stressors during their training and are at risk for emotional and mental health problems. This study can serve as a basis for future research, advocacy and resource application for overall improvements to well-being dur- ing residency.
Competing interests
All of the authors have in the past or are currently serving as volunteers for the Canadian Association of Internes and Residents.
Authors' contributions
JC conceived the study, designed the questions and was responsible for coordination of the pilot project in Alberta, which was published in BMC Medical Education in June 2005 [8]. JC, YL, and LH were involved in expand- ing the pilot project into a national scale survey and coor- dinated survey distribution through all of the CAIR board members. SP was involved in expanding the pilot project into a national survey, data analysis and editing of the manuscript. All of the authors were involved in the devel- opment of the manuscript for publication. YL was involved in the final formatting and editing for submis- sion.
Additional material
Acknowledgements
We would like to thank all members of the Canadian Association of Internes and Residents (CAIR) who participated in this survey and who were brave enough to discuss the stress they were incurring during resi- dency training. This Well-being survey would not have been possible with- out the dedication of all of the CAIR board members who diligently distributed and collected these surveys to Canadian Residents. We also thank the Provincial Housestaff Organizations who make up CAIR, as they were instrumental in the administration and success of the survey. These include the Professional Association of Residents of British Columbia (PAR- BC), Professional Association on Residents of Alberta (PARA), Professional Association of Internes and Residents of Saskatchewan (PAIRS), Profes- sional Association of Residents and Interns of Manitoba (PARIM), Profes- sional Association of Internes and Residents of Ontario (PAIRO), Professional Association of Residents in the Maritime Provinces (PARI-MP), and the Professional Association of Internes and Residents of Newfound- land (PAIRN). Appreciate the contributions of Dr. Michael Myers for his helpful suggestions in the preparation of the final manuscript. Finally, we thank the Canadian Post MD Educational Registry (CAPER) for their work on managing the data.
References
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Additional file 1
The Happy Docs Survey Questions. Word file with the original questions from the Happy Docs Survey.
Click here for file
[http://www.biomedcentral.com/content/supplementary/1756- 0500-1-105-S1.doc]
Table 5: Estimated lifetime risk of psychiatric disorders in residents
Psychiatric Disorder Number reported; and Percentage Positive Predictive Value* Lifetime Risk* (%)
Depression 1345; 67 0.23 15
Social Phobia 346; 17 0.39 7
Agoraphobia 147; 7 0.85 6
Panic Disorder 622; 31 0.08 2
Mania 238; 12 0.12 1
*Positive predictive values and lifetime risks are based upon positive screens and resultant lifetime risk associated from the Canadian Community Health Survey (CCHS)
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BioMedcentral 6. Martini S, Arfken CL, Churchill A, Balon R: Burnout Comparison
Among Residents in Different Medical Specialties. Academic Psychiatry 2004, 28:240-242.
7. Myers MF: Commentary: on the importance of anonymity in surveying medical student depression. Academic Psychiatry 2003, 27(1):19-20.
8. Cohen JS, Patten S: Well-being in residency training: a survey examining resident physician satisfaction both within and out of residency training and mental health in Alberta. BMC (Medical Education) 2005, 5:21.
